Screening for intimate partner violence in an oncology population.

Intimate partner violence (IPV) is most broadly defined as behavior that is abusive and perpetrated by someone who is in a current or previous relationship with the victim (Nelson, Bougatsos, & Blazina, 2012); see Table 1. Intimate partner violence may occur on a continuum ranging from isolated incidents described as situational couple violence to intimate terrorism encompassing multiple aspects of psychological and physical abuse (Johnson, 2008). Although few studies have focused solely on the oncology population, a 2006 study by Modesitt and colleagues states that a staggering 75% of women under treatment for breast, ovarian, endometrial, or ovarian cancer report having experienced some form of intimate partner abuse during adulthood (Modesitt et al., 2006). Results from a 2002 National Violence Against Women Survey confirmed this high rate of incidence (Canady, Naus, & Babcock, 2010).

I ntimate partner violence (IPV) is most broadly defined as behavior that is abusive and perpetrated by someone who is in a current or previous relationship with the victim (Nelson, Bougatsos, & Blazina, 2012); see Table 1. Intimate partner violence may occur on a continuum ranging from isolated incidents described as situational couple violence to intimate terrorism encompassing multiple aspects of psychological and physical abuse (Johnson, 2008). Although few studies have focused solely on the oncology population, a 2006 study by Modesitt and colleagues states that a staggering 75% of women under treatment for breast, ovarian, endometrial, or ovarian cancer report having experienced some form of intimate partner abuse during adulthood (Modesitt et al., 2006). Results from a 2002 National Violence Against Women Survey confirmed this high rate of incidence (Canady, Naus, & Babcock, 2010).

SCREENING RECOMMENDATIONS
In January 2013, the US Preventive Services Task Force (USPSTF) issued a recommendation for health-care providers to begin routine screening of women patients for IPV (USPSTF, 2013). The USPSTF's recommendation aligns with the 2011 recommendation by the Institute of Medicine that all women of childbearing age should be routinely screened by their health-care provider for IPV (Kottenstette & Stulburg, 2013). These recommendations are based on current evidence that screening and intervention in the health-care setting reduce both the incidence of IPV and the related health outcomes. Intimate partner violence and oncology intersect because IPV occurrence is • Physical violence is when a person hurts or tries to hurt a partner by hitting, kicking, or using another type of physical force.
• Sexual violence is forcing a partner to take part in a sex act when the partner does not consent.
• Threats of physical or sexual violence include the use of words, gestures, weapons, or other means to communicate the intent to cause harm.
• Emotional abuse is threatening a partner or his or her possessions or loved ones or harming a partner's sense of self-worth. Examples include stalking, name-calling, intimidating, or not letting a partner see friends and family.
Note. Information from CDC (2012). a Often, IPV starts with emotional abuse. This behavior can progress to physical or sexual assault. Several types of IPV may occur together. a public health concern; the reported incidence of IPV ranges from 22% to 39% over a woman's lifetime. This high rate of incidence greatly increases the likelihood that oncology patients may experience IPV in addition to their cancer diagnosis (Cesario, in press). Although current recommendations are for screening women of childbearing age, older women also have the potential to be vulnerable to IPV (Sawin & Parker, 2011). In addition to the likelihood that older women may remain in an abusive relationship because of financial dependence, older women are also at increased risk to sustain injury if physical abuse and neglect occur (Sawin & Parker, 2011).

FREQUENTLY USED TOOLS
No single IPV screening tool is routinely used in practice or has, to date, well-established psychometric properties (Rabin, Jennings, Campbell, & Bair-Merritt, 2009). However, the most frequently used screening tools in this review included the Women's Experience with Battering (WEB) Scale and the Psychological Maltreatment of Women Inventory (Short-Form); see Appendices A and B on pages 459 and 460. Both tools provide basic screening questions for patients in the clinical setting (Tolman, 1989). These screening tools provide the additional benefit of sensitivity in screening for emotional IPV (Sawin & Parker, 2011).
Owen-Smith and colleagues (2008) identified advanced practitioners as the health-care providers most able to integrate IPV screening into their practice. Advanced practitioners routinely assess oncology patients in the outpatient setting and facilitate referrals, which may include psychosocial support. Advanced practitioners also routinely spend significant time with the patient assessment, allowing for an opportunity to develop rapport and encourage domestic violence disclosure (Owen-Smith et al., 2008). Survivors of IPV recommend repeated screenings, as this routine may facilitate future disclosure of abuse (Owen-Smith et al., 2008). In fact, a literature review with case examples by Schmidt, Woods, and Stewart (2006) noted that in each of the case studies presented, neither the oncologist nor the nurses identified the abuse based on injury or suspicious behavior; patients had been referred to psychiatry for "evaluation of mood."

ROUTINE APPROACH
Screening for IPV may be uncomfortable for health-care providers, so using a routine approach for all female patients may be most efficacious; providing a statement disclosing that the policy of the health-care provider is to screen all female patients diminishes the burden of trying to implement a targeted screening. When health-care providers routinely assess for IPV as part of the standard psychosocial assessment, they should (a) be aware of their state laws for reporting a positive screening, (b) remain nonjudgmental and supportive when IPV screening is positive and provide resource information, and (c) facilitate referral to the appropriate social services when indicated (Mick, 2006). Resources for the advanced practitioner and the patient can be found in Table 2. Following are a number of statements that women have used to describe their relationships with their male partners. Please read each statement and then circle the answer that best describes how much you agree or disagree in general with each one as a description of your relationship with your partner. If you do not now have a partner, think about your last one. There are no right or wrong answers; just circle the number that seems to best describe how much you agree or disagree with it.

Scoring Instructions
Items are reverse-scored and then summed. Scores can range from 10 to 60. A score of greater than 19 indicates battering.
Note. Reprinted from Smith et al. (2002). Used with permission from Sage Publications.